Dr.C.S.Jamunanantha (MBBS, DTCD, SMO, TH, Jaffna)
The first patient with Kidney disease of unknown origin was identified in 1991 and then subsequently every four years the numbers doubled. And secondly the Kidney disease spread from Rajarata to the other territories to Pollonnaruwa and Moneragala. It has spread up to Trincomalee down to Moneragala and Badulla. We can observe the Chronic Renal failure patients treated at Teaching Hospital, Jaffna also increased when we were medical students in 1992, during our two months clinical appointment we were able to see about two or three Chronic Renal failure patients. But now it is ten times high. Every day there is around 20 admissions for dialyses or epo injection.
The third issue was that the patients who were affected were getting younger from the 40’s to 30’s and then to, 20’s. In 1996, 2 percent of the population was affected in those territories, by 2000, 4 percent were affected. By 2004, 8 percent were affected, by 2008, 16 percent were affected.
The Health Ministry and the WHO tried to do two things – They were trying to treat the affected patients. Secondly they were researching the cause of the Kidney disease. Taking the behaviour of the patients and studying what factors were common in these patients, they found five things:
One is the drinking water, the other was food, the third was agro chemicals, fourth was their occupation (most were farmers affected) and fifth was the geography. They could fairly see that if the source of water was safe they did not have trouble. So in that context giving unpolluted water was one of the ways of these patients.
Their change of approach was to go for an evidence based approach – the factors, common in these patients, “To do that, we have to have a public health approach/ preventive health approach. The basic concept we evolved was we cannot just confine ourselves to the curative sector – just to treat patients. We have to have evidence collecting system and a public health approach.
12 PROPOSALS FOR COMBATING CKDU
*Proposal 1 – Establish a comprehensive health program on CKDU within the Ministry of Health.
*Proposal 2 – Develop strategies to prevent and control CKDue based on the best available evidence.
*Proposal 3 – Establishing a surveillance system for chronic non communicable diseases.
*Proposal 4 – Establish a common research agenda to streamline scientific research conducted with the funds of the government sector institutions.
*Proposal 5 – Establish a mechanism for collection of specimens needed for further evidence gathering for CKDue.
*Proposal 6 – Improving the resources available for laboratory diagnosis for evidence gathering on CKD.
*Proposal 7 – Redefining safety regulatory for water, food in relation to materials.
*Proposal 8 – Establish a CKDue advocacy initiative through the heath education bureau to facilitate health promotion initiatives.
*Proposal 9 – Program, to look after the children who lost their patients due to CKDue
*Proposal 10 – Building the capacity of the Ministry of Health to contribute adequately to other health related sectors in order to safeguard health concerns of the public.
*Proposal 11 – Appointing clinicians with expense in toxicology to support the-CKDue public health program.
*Proposal 12 – Enhancement of the Curative settings at the local level.
Principally there should to be two main objectives. Initially we should treat the patients who are suffering from kidney failure. For which we need further expansion of medical facilities including sufficient dialysis and kidney transplant.
More importantly we have to protect the unaffected people in the region. This needs proper more individualized health education programs and provision of safe drinking water. To minimize further pollution, agro-chemicals with nephrotoxic compounds need to be regulated.
The geographic pattern of CRF is extending Northern Province too. It is more related to agriculture product vegetables and paddy consumptions. The coastal area fishing community has less case. There is no sex difference in causation of CRF. The age of occurrence of CRF also varied from pediatric to elders.
For epidemiological Analysis the following observation should be considered.
- All the elders do not get CRF even in the so called Risk Zone for CRF.
- All the Adults do not get CRF in the CRF Risk Zone.
- All the Children’s do not get CRF in the CRF Risk Zone.
Hypothesis A – CRF Risk Zone has increased trend to develop CRF with some uncertain augmenting factors.
Same feature is applicable to Jaffna district too. But Chronic Renal failure cases are reported not only in CRF Risk Zone but also adjacent geographical areas.
Hypothesis B – Consumption of Paracetomol even at therapeutic level will lead to CRF in C RF Risk Zone.
It is clearly observed all the victims of CRF have been treated with paracetomol during last 5 years before developed CRF irrespective of age.
So the culprit drug is the paracetomol which augment the CRF in CRF Risk Zone and the adjacent areas. It is by the Synergistic mechanism. It means paracetomol at therapeutic level 10-20μg/ml also toxic to nephrons in CRF Risk zone. Paracetomol is having antipyretic activity. If the level exceed 300μg/ml 50% Renal cells will undergo apoptosis. Further paracetomol induced cell death is caspase dependant. So even in the therapeutic dose, the people living in CRF Risk areas shall develop Synergistic action of caspase activity)
Paracetomol – normally metabolized in Liver and Kidney by P 450 enzymes. But due to poisoning with Arsenic, Cadmium and other agrochemical P 450 metabolizing enzymes will be suppressed and lead to CRF.
Further paracetomol has a phenacetin metabolite. The phenacetin is the most Nephro toxic substance and banned in many country.
It is very sad any expert in Sri Lanka do not highlight the Synergistic effect of paracetomol is the culprit of causing of CRF in Sri Lanka.
Indiscriminate use of paracetomol and easy availability of paracetomol in local shops also should be banned. If we have to reduce paracetomol consumption 95% , we can reverse the CRF incidence in Sri Lanka. Especially in CRF Risk Zone.
- Mazer, M., Perrone, J., Acetaminophen induced Nephro toxicity, Path physiology, Clinical Manifestations and Management, J.Med. Toxicol, 2008 Nar: 4(1):2-61.
- Lorira Lory, Paracetomol induced Renal tubular Injury – A Role for ER stress, JASN- Journal of the American Society of Nephrology., JASN, Feb. 2004, Vol.15, No.2, Page 380-389.